Original Article

Mobility therapy and central or peripheral catheter-related

adverse events in an ICU in Brazil*
Realização de fisioterapia motora e ocorrência de eventos adversos
relacionados a cateteres centrais e periféricos em uma UTI brasileira

Natália Pontes Lima, Gregório Marques Cardim da Silva,

Marcelo Park, Ruy Camargo Pires-Neto

Abstract
Objective: To determine whether mobility therapy is associated with central or peripheral catheter-related
adverse events in critically ill patients in an ICU in Brazil. Methods: A retrospective analysis of the daily
medical records of patients admitted to the Clinical Emergency ICU of the University of São Paulo School of
Medicine Hospital das Clínicas Central Institute between December of 2009 and April of 2011. In addition to the
demographic and clinical characteristics of the patients, we collected data related to central venous catheters
(CVCs), hemodialysis (HD) catheters and indwelling arterial catheters (IACs): insertion site; number of catheter
days; and types of adverse events. We also characterized the mobility therapy provided. Results: Among the
275 patients evaluated, CVCs were used in 49%, HD catheters were used in 26%, and IACs were used in 29%. A
total of 1,268 mobility therapy sessions were provided to patients while they had a catheter in place. Catheter-
related adverse events occurred in 20 patients (a total of 22 adverse events): 32%, infection; 32%, obstruction;
and 32%, accidental dislodgement. We found that mobility therapy was not significantly associated with any
catheter-related adverse event, regardless of the type of catheter employed: CVC—OR = 0.8; 95% CI: 0.7-1.0;
p = 0.14; HD catheter—OR = 1.04; 95% CI: 0.89-1.21; p = 0.56; or IAC—OR = 1.74; 95% CI: 0.94-3.23; p =
0.07. Conclusions: In critically ill patients, mobility therapy is not associated with the incidence of adverse
events involving CVCs, HD catheters, or IACs.
Keywords: Physical therapy modalities; Intensive care units; Catheters; Early ambulation.

Introduction
Early rehabilitation in intensive care unit
(ICU) patients helps to prevent and minimize
the deleterious effects of immobility, to improve
functional capacity, and to reduce the duration
of mechanical ventilation and length of hospital
stay, as well as improving the quality of life
of such patients.(1-4) However, the literature
describes some barriers that limit or preclude
this rehabilitation. Some examples are disease
severity, level of sedation, use of vasoactive drugs,
and presence of catheters, whether central or
peripheral.(5,6)
The use of central or peripheral catheters for
drug administration and monitoring in critically
ill patients is common. In patients with difficult
access, with multiple access sites, or with a bleeding
disorder, partial or total confinement to bed to
prevent catheter dislodgement or loss is still
common. In addition, there is the concern about
maintaining blood flow in patients undergoing
continuous renal replacement therapy.(7)
Recent studies have shown that mobilization
of patients with catheters is safe and is not
associated with access-related or catheter-related
adverse events.(6,8,9) However, some centers still
consider the presence of catheters a barrier to
mobilization, delaying the start of rehabilitation.(5,10)

1. Physical Therapist. Department of Physical Therapy, Hospital das Clínicas Central Institute, University of São Paulo School of
Medicine, São Paulo, Brazil.
2. Physician. Intensive Care Unit, Department of Clinical Emergencies, University of São Paulo School of Medicine Hospital das
3. Clínicas Central Institute, São Paulo, Brazil.
Physical Therapist. Department of Pathology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
*Study carried out at the Hospital das Clínicas Central Institute, University of São Paulo School of Medicine, São Paulo, Brazil.
Correspondence to: Natália Pontes Lima. Faculdade de Medicina, USP, Avenida Dr. Arnaldo, 455, sala 1155, CEP 01246-903,
São Paulo, SP, Brasil.
Tel. 55 11 2266-6470. E-mail: nataliaponteslima@yahoo.com.br
Financial support: None.
Submitted: 9 June 2014. Accepted, after review: 10 February 2015.

http://dx.doi.org/10.1590/S1806-37132015000004338 J Bras Pneumol. 2015;41(3):225-230

226 Lima NP, Silva GMC, Park M, Pires-Neto RC
Given that the literature on this topic is
controversial and that most studies were conducted
in centers in the United States and Australia, all
of which provide physical therapy that is different
from that provided in Brazil, the objective of the
present study is to determine whether mobility
therapy is associated with central or peripheral
catheter-related adverse events in critically ill
patients in an ICU in Brazil. Our hypothesis is
that there is no association between mobility
therapy and central or peripheral catheter-related
adverse events such as accidental dislodgement
or removal and infection.
Methods
This study was approved by the Human
Research Ethics Committee of the Faculdade de
Medicina da Universidade de São Paulo (FMUSP,
University of São Paulo School of Medicine).
We performed a retrospective analysis of
the daily medical and physical therapy records
of patients admitted to the 6-bed ICU of the
Department of Clinical Emergencies of the FMUSP
Instituto Central do Hospital das Clínicas (ICHC,
Hospital das Clínicas Central Institute) between
December of 2009 and April of 2011. The daily
record forms were developed prior to the study,
were completed electronically, and had been in
use for at least one year in the ICU. Therefore,
data on all study variables were available through
an electronic medical records system.
Physical therapy in the ICU was characterized
by respiratory therapy and by mobility therapy.
In brief, respiratory therapy was based on airway
clearance maneuvers (including aspiration), lung
expansion techniques, adjustment of oxygen
therapy, and inhalation therapy (the last of these
being administered as medically prescribed). In
addition, if the patient was mechanically ventilated,
the physical therapist also assisted in adjustment
of ventilator settings and in patient extubation.
Mobility therapy consisted of upper limb, lower
limb, and trunk exercises, in passive, active, and
resistive modes. Exercise was performed with the
patient lying on the bed, sitting on the bed, or
sitting in an armchair, depending on the ability of
the patient and at the discretion of the physical
therapist. In addition, exercise in the standing
position and ambulation around the bed and
in the hallway was recommended.
The ICU multidisciplinary team comprised 1:6
nurse/patient, 1:2 nursing technician/patient,
J Bras Pneumol. 2015;41(3):225-230
1:6 resident in physical therapy/patient, and
1:10 senior physical therapist/patient. Physical
therapy was available 12 hours a day (from 7:00
a.m. to 7:00 p.m.), and, during that period, each
patient usually received two visits, which were
tailored to the needs of each individual.
Data collection included demographic
characteristics and clinical data, such as age,
gender, clinical admission diagnosis, Simplified
Acute Physiology Score (SAPS) 3, site of admission,
duration of mechanical ventilation, length of
ICU stay, and mortality. In addition, we collected
data related to central venous catheters (CVCs),
hemodialysis (HD) catheters, and indwelling
arterial catheters (IACs): insertion site; number
of catheter days; and number of mobility therapy
sessions conducted with a catheter in situ. The
catheter-related adverse events considered were
obstruction, accidental dislodgement or removal,
and infection. The data we collected on mobility
therapy included the frequency and level of each
activity (in-bed exercise, sitting on the edge of
the bed or out of bed, standing, and walking). All
data were entered into tables and were checked
by two researchers.
Statistical analysis was performed with
Statistical Package for the Social Sciences, version
15.0 (SPSS Inc., Chicago, IL, USA). Descriptive
analysis was performed using frequency of
each event (percentage), mean (SD), or median
(interquartile range [IQR]), when appropriate.
For each catheter type (CVC, HD catheter, and
IAC), we determined the number of patients who
experienced a catheter-related adverse event and
the number of those who did not. Therefore, the
patients were divided into two groups on the
basis of presence or absence of catheter-related
adverse events. We used the nonparametric Mann-
Whitney test to compare the adverse event and
non-adverse event groups in terms of number
of catheter days and number of mobility therapy
sessions, for each catheter type. Logistic regression
analysis (including ORs and their 95% CIs) was
performed to determine the association between
adverse events and number of mobility therapy
sessions. The association analysis was adjusted for
number of catheter days (confounding variable).
For statistical analysis, the level of significance
was set at 5% (p < 0.05).
http://dx.doi.org/10.1590/S1806-37132015000004338
Mobility therapy and central or peripheral catheter-related adverse events in an ICU in Brazil
Results
During the study period, 275 patients were
admitted to the Clinical Emergency ICU of the
ICHC-FMUSP, all of whom were included in the
analysis. Patient demographic characteristics and
clinical data are shown in Table 1. The mean
age of the patients was 48 ± 18 years, and
most patients (84%) were admitted for clinical
decompensation. The remaining 16% were admitted
for surgical reasons (postoperative period). In
addition, of the 275 patients, 82 (30%) were
admitted with a diagnosis of sepsis. The major
source of origin was the emergency room (in
53%), followed by the ward because of clinical
worsening (in 26%). The length of ICU stay
was 5 [IQR: 7] days, and 44% of the patients
required invasive mechanical ventilation during
that period. Overall ICU mortality was 17%.
Of the 275 patients, 82% (n = 225) received
at least one mobility therapy session (a total of
2,638 sessions) and 94% (n = 258) received at
least one respiratory therapy session throughout
their ICU stay. In addition, of those 275 patients,
31% (n = 86) sat in an armchair (i.e., out of bed)
and 29% (n = 80) walked at least once during
their ICU stay. Patients with orotracheal tubes
(orotracheal intubation) or tracheostomy tubes
(with or without mechanical ventilation) underwent
a total of 1,428 mobility therapy sessions, in
which the main activity was ambulation, in 237
Table 1 - Patient demographic characteristics.a
Variable (n = 275)
Age, years 48 ± 18
Male gender, n (%) 135 (49)
SAPS3 38 ± 19
Diagnosis, n (%)
Clinical 229 (84)
Surgical 45 (16)
Site of admission, n (%)b
Emergency room 145 (53)
Ward (clinical worsening) 72 (26)
Operating room (PO) 45 (16)
Others 12 (4)
Mechanically ventilated patients, n (%) 122 (44)
Duration of mechanical ventilation, daysc 3 [4]
Length of ICU stay, daysc 5 [7]
Mortality, n (%) 47 (17)
SAPS: Simplified Acute Physiology Score; and PO:
postoperative period. aValues expressed as mean ± SD,
except where otherwise indicated. bInformation unavailable
for four patients. cValues expressed as median [interquartile
range].
http://dx.doi.org/10.1590/S1806-37132015000004338
227
sessions; orthostasis, in 161 sessions; sitting in
an armchair, in 91 sessions; sitting on the edge
of the bed, in 60 sessions; and in-bed exercise,
in 879 sessions. During those sessions, there
were no reports of self-extubation or accidental
extubation.
Table 2 shows the frequency of patients who
experienced catheter-related adverse events by
catheter type, as well as the number of catheter
days, the frequency of mobility therapy sessions
conducted with a catheter in situ, and the most
successfully accomplished activity in those sessions,
by catheter type and by absence or presence of
catheter-related adverse events. Among the 275
patients evaluated, CVCs were used in 49%, HD
catheters were used in 26%, and IACs were used
in 29%. In addition, 86 patients (31%) required
different types of catheters simultaneously.
The main insertion sites were the jugular and
subclavian veins, for CVCs and HD catheters,
and the radial artery, for IACs. A total of 1,268
mobility therapy sessions were conducted with a
catheter in situ, and the most prevalent activity
was in-bed limb mobilization (in passive, active,
and resistive modes). Catheter-related adverse
events occurred in 20 patients, and, in two of
those 20 patients, there were two adverse events
(a total of 22 catheter-related adverse events).
The adverse events were as follows: infection
(n = 5, CVC; n = 2, HD catheter); obstruction
(n = 5, HD catheter; n = 2, IAC); and accidental
dislodgement or removal (n = 4, CVC; n = 1, HD
catheter; n = 2, IAC). In one case, the cause of
the adverse event was not recorded on the chart.
When comparing the adverse event and
non-adverse event groups by catheter type, we
found that the number of catheter days was
greater in the former than in the latter—(median
[IQR]) 8 [10] vs. 5 [4] days for CVCs (p < 0.05);
and 7 [15] vs. 3 [4] days for IACs (p < 0.05)—as
was the number of mobility therapy sessions per
patient—(median [IQR]) 12 [19] vs. 4 [9] for HD
catheters (p < 0.05). Logistic regression analysis
for each catheter type, adjusted for number of
catheter days, revealed that mobility therapy was
not significantly associated with any catheter-
related adverse event, regardless of the type of
catheter employed: CVC—OR = 0.862; 95% CI:
0.7-1.05; p = 0.146; HD catheter—OR = 1.046;
95% CI: 0.898-1.219; p = 0.562; or IAC—OR =
1.746; 95% CI: 0.942-3.237; p = 0.077.
J Bras Pneumol. 2015;41(3):225-230
228 Lima NP, Silva GMC, Park M, Pires-Neto RC

Table 2 - Characteristics of the catheters used and of the mobility therapy provided.
Variable CVC HD catheter IAC
Adverse event Adverse event Adverse event
Absent Present Absent Present Absent Present
Patients, n (%) 126 (94) 8 (6) 63 (89) 8 (11) 75 (95) 4 (5)
Catheter days, median [IQR] 5 [4] 8 [10]* 6 [7] 9 [16] 3 [4] 7 [15]*
Mobility therapy sessions (n), median [IQR]a 4 [5] 6 [13] 4 [9] 12 [19]* 2 [3] 10 [22]
Main insertion siteb,c
Jugular vein, n 85 5 34 5 - -
Subclavian vein, n 33 3 11 1 - -
Femoral vein, n 6 1 17 2 - -
Radial artery, n - - - 50 3
Dorsalis pedis artery, n - - - - 15 0
Femoral artery, n - - - - 3 1
Most successfully accomplished activity
Ambulation, n 23 2 125 0 3 0
Orthostasis, n 51 3 101 2 5 0
Sitting in an armchair, n 25 3 38 3 7 0
Sitting on the edge of the bed, n 36 2 39 8 5 1
Limb mobilization, n 533 42 382 59 227 20
CVC: central venous catheter; HD: hemodialysis; IAC: indwelling arterial catheter; and IQR: interquartile range. aMobility
therapy sessions received by each patient with a catheter in situ. bThere can be more than one insertion site in each
individual patient. cThe insertion site was not described on the chart in 3% (CVC); 4% (HD catheter), and 9% (IAC) of
the cases. *p < 0.05 when compared with the respective non-adverse event group.

Discussion However, the large number of physical therapists

In the present study, we found that, of the
275 patients admitted to the Clinical Emergency
ICU of the ICHC-FMUSP, 82% received mobility
therapy, whereas 94% received respiratory therapy.
Of a total of 2,638 mobility therapy sessions,
1,268 were provided to patients while they had
a catheter in place (CVC, IAC, or HD catheter),
and we found that mobility therapy was not
significantly associated with any catheter-related
adverse event, regardless of the type of catheter
employed. In addition, in 1,428 sessions provided
during orotracheal intubation or during the use of
a tracheostomy tube (with or without mechanical
ventilation), there were no reported episodes of
self-extubation or accidental extubation.
Recent cohort or prevalence studies have
found that 34 to 62% of ICU patients receive
mobility therapy.(9,11,12) In our study, 82% of the
patients received at least one mobility therapy
session. This difference in the proportion of
treated patients can be explained by the large
number of physical therapists in our ICU (1:10
senior physical therapist/patient and 1:6 resident
in physical therapy/patient), unlike what occurs
in ICUs in other countries, in which there is
a strong presence of respiratory therapists.(13)
did not imply treatment aimed at more complex
levels of mobilization, the most prevalent activity
being in-bed exercise. One explanation for this
finding is that early mobilization in ICUs in
Brazil remains unusual, despite the constant,
daily presence of the physical therapist. Another
factor that can explain this situation is that
only the activities conducted with a catheter in
situ were analyzed, and patients with CVCs and
IACs usually experience increased hemodynamic
instability and increased disease severity.
In our study, we found no association between
catheter-related adverse events and mobilization
(mobility therapy) in the ICU. In addition, the
incidence of catheter-related adverse events was
2% in our study (22 events in 1,268 sessions),
being similar to the less than 5% incidence
reported in other centers.(1,2,14-18) Damluji et al.,(6)
when evaluating 101 patients who underwent
253 physical therapy sessions with a femoral
catheter in situ, found that exercise was not
associated with catheter-related adverse events.
Perme et al.,(8) when evaluating 77 patients with
92 femoral catheters (50 IACs, 15 CVCs, and
27 HD catheters), found that exercise was not
associated with catheter-related thrombotic or
obstructive complications. Likewise, we found

J Bras Pneumol. 2015;41(3):225-230 http://dx.doi.org/10.1590/S1806-37132015000004338

Mobility therapy and central or peripheral catheter-related adverse events in an ICU in Brazil
no association between mobility therapy and
catheter-related adverse events. However, unlike
in the aforementioned studies, we assessed not
only the femoral site but also the jugular and
subclavian sites, for CVCs and HD catheters, and
the radial and dorsalis pedis arteries, for IACs.
In fact, the most common catheter insertion
sites were the radial and jugular sites, given
that catheter insertion into the femoral site is
not the primary option in our ICU (Table 2).
Therefore, even when different insertion sites
were used, exercise did not imply an increase in
the number of catheter-related adverse events.
The present study has some limitations. First,
this was a single-center study—direct comparison
with other hospitals in Brazil should be conducted
with caution. However, our findings are similar to
those of studies conducted in countries where the
difference in care is greater than that observed
among hospitals in Brazil. Second, the study has
a retrospective design—data were retrieved from a
database and from patient charts. Therefore, we
can establish only an association, not a cause-
and-effect relationship. In addition, information
on catheter insertion site could not be obtained
for all cases—that is, for 3% (CVC), 4% (HD
catheter), and 9% (IAC)—nor was it possible to
obtain information on one CVC-related adverse
event. However, we believe that these factors
do not alter the results of this study, because
catheter insertion site was not used for analysis,
being of descriptive value only. Third, the only
factors used in our analysis were mobility therapy
and number of catheter days. Thus, it was not
possible to determine the effect of medical and
nursing procedures (e.g., hygiene, transport, and
tube passage) on our results. Catheter infection
is known to be caused by multiple factors and
can result from patient handling by healthcare
workers. For this reason, the reported prevalence,
which refers specifically to mobility therapy,
might be overestimated relative to reality.
On the basis of the present study, we conclude
that, in the study population, mobility therapy
is not associated with the incidence of adverse
events involving CVCs, HD catheters, or IACs.
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